Militant moderate, unwilling to concede any longer the terms of debate to the strident ideologues on the fringe. If you are a Democrat or a Republican, you're an ideologue. If you're a "moderate" who votes a nearly straight party-ticket, you're still an ideologue, but you at least have the decency to be ashamed of your ideology. ...and you're lying in the meantime.

Sunday, November 11, 2012

A Torpedo to the Ship of State

Some internet acquaintances tried to tell me that up was down and black was white last week and I corrected them. Those who were corrected took great offense from it and either disappeared or stood on the sides sniping, while others thought the conversation was quite interesting and informative.

The conversation naturally had political overtones, and dealt with insurance ... so you can guess which particular tones were political.

One of the many points I made in attempting to get these people to understand what insurance is designed to do and how insurance is currently being misused to the point of insanity by politicians willing to buy cheap votes by selling my children, my grandchildren, and your own, is that “preventive care” spends more money to detect a rare medical condition than is saved by finding it earlier than later ... thus it is not a proper thing for insurance to cover.

“It saves lives!!” I was told in capital letters.

Not the issue, I said. The issue is the cost of saving those lives, and how much money we are digging out of our pockets to pay the insurance companies to pay for the routine care which includes health screenings ... exactly the way insurance was not designed to work. Demanding that insurance cover this type of thing becomes inflationary. This is the point that was ignored.

This morning, to highlight my argument, comes a medical study done in Britain and published in their medical journal, The Lancet, saying that for every woman saved from breast cancer through mammogram screening, 3 are “overdiagnosed”, and other fascinating numbers. “Overdiagnosed” patients are given surgery when cheaper radiation would do; given radiation when cheaper chemo would do, given chemo when doing nothing would do. Yes, there are apparently many cancers that grow too slowly or not at all to ever worry about. Who knew?

Also noted in the study are a “significant” number of false positives which result in costly follow-ups and further treatments that ultimately prove unnecessary.

Some numbers from the study:

1] every year 300,000 British women aged 50-52 are offered their first routine 3-year mammogram

2] of all women screened annually [article doesn’t give this number but it’s undoubtedly well into the millions], 5,300 are diagnosed with breast cancer each year

3] of those 5,300, four thousand – over 75% – are “overdiagnosed” and given too much treatment than is necessary

4] there are, by implication, tens of thousands more who are given “false positives” and undergo unnecessary treatment until they find out it was a false alarm

5] there are still several million mammograms handed out annually of which all but a few tenths of one-percent – to be conservative [which is to say, exaggerating the risk] – ultimately shows nothing.

I am perfectly aware that mammograms save lives; I am perfectly aware that a mammogram which shows nothing makes people feel better in knowing that nothing is wrong. That is not the issue.

The issue is what all this costs, and why demanding that “everyone” pay for it is stupid.

Britain’s health care system – a single-payer monstrosity, and which is going broke, and which does an abysmal job at any rate – hands out mammograms every three years starting at the age of 50. There are 300K women in the 50-52 year age cohort, nearly a third of a million getting mammograms each year. The 53-55 year cohort will probably have almost as many, the 56-58 year cohort almost as many as the prior, etc. Shall we say for the sake of making the hypothetical math simpler that there are 5,300,000 women under Britain’s socialized medicine getting mammograms each year?

Of that figure, 5,300 are diagnosed with breast cancer. The risk of being diagnosed with breast cancer in any given year in Britain is 0.2%. Two out of a thousand; one in 500. I’m going to assume British women are similar to American women, for that is American’s breast cancer rate.

A mastectomy – far and away the most common treatment – costs between $15K and $55K in the US – $35K average [without reconstruction]. To claim this screening was cost-effective, the cost of 500 mammograms would be required to be less than the difference in cost between breast cancer treatment when the cancer was caught early and the cost of that treatment when it was caught late. Sadly, there is no statistical difference in cost, so no matter what a mammogram costs it isn’t a cost-effective screening technique.

If we could be satisfied that the screening doesn’t cost us more than the actual thing being screened for, the 500 mammograms would have to cost no more than $70 each. But they don’t.

The average mammogram in the US costs $100, as it includes the services of the x-ray tech, the radiologist, the equipment and supplies ... And insurance [in the US, in Britain the government] pays for it. Even when mammograms are “free”, someone is still paying for it – frequently city and county governments who operate clinics at cost. The average includes these. Mammograms frequently run to near $1,000 – so let’s work from the average.

When insurance pays for the mammogram, it means that the insurance company is going to charge its customers more than it’s paying out for the x-ray, because just like the radiologist has his medical school, staff and equipment to pay for, so does the insurance company have its investigators, claims adjusters, actuaries, clerical workers and office supplies. And so is the British government paying out for these extras.

Insurance is going to ultimately charge you $150 and probably closer to $200 to pay for that $100 mammogram every three years starting at the age of 50 – in the US, the age routine screening starts is 40, so that simply adds ten years of $200 insured mammograms that the doctor charges $100 for.

Chemotherapy, instead, is the least expensive of the traditional medical treatments for breast cancer. The average cost of chemo is $15K in the US. Yes, there are some drugs that cost a whole hell of a lot more and $15K is simply for one dose, but insurance works off statistics so we’re using the average. In order to make 500 screenings cost no more than the breast cancer cured by chemo, the mammogram would have to be $30 each. The average mammogram still costs $100, for which the insurance company will collect between $150 and $200 to give away “for free”.

Five hundred $100 mammograms to detect one $35K mastectomy or one $15K chemo are going to cost someone $50,000 to provide. Because insurance companies – whether government-mandated or otherwise – are just the middlemen in this transaction and they have to make a profit in order to stay in business, the someone coughing up the $50,000 will not be them. It will instead be the customers of the insurance company. Or, when the government starts buying insurance for those it feels sorry for, it will be the taxpayers.

We’ll be paying $200 to get $100 of preventive service that is useful to only one person while being medically irrelevant to 499 others. Insurance is designed to pay for breast cancer treatment – it is a rare condition that is very expensive to treat. And whether it is caught early or late, the cost remains the same; what doesn’t remain the same is the survival rate. 500 women could insure themselves for breast cancer treatment for $100 a year – only one-in-500 will get breast cancer, the risk is shared across the group because it is a rare event. But to insure for breast cancer treatment AND its preventive screenings costs $300 a year.

The risk of having a preventive screening cannot be “shared” across the group because the risk is damnear 100%. Risk this great turns the insurance company into a middleman of a guaranteed service. You may as well hire someone to pay your electric bill and phone bill and water bill and trash bill and mortgage each month. Do you think it’s cheaper to hire someone to do it for you than it is to do it yourself?

That’s right, it’s not. These people are called “personal assistants” in Hollywood, and are paid, typically, six figures. How does “competition” lower the total cost of your monthly utility bills and mortgage when you hire a personal assistant to do it for you?

That’s right, it doesn’t. Your utility bills are still $700 per month, and your mortgage is $900. You’re still paying $1,600 a month for these. Having someone else do it for you only means that you’re paying the someone else on top of those other bills. It is not cheaper; it is more expensive.

Additionally, for every real diagnosis there are several false positives. Let’s say, for ease of math, not to mention accuracy of thesis, ten. There are ten false positives to every true positive.

Each false positive requires a follow-up imaging; another x-ray or, increasingly, an MRI [I’m ignoring the even more costly biopsy]. An MRI is $500 [minimum], for which the insurance company charges $1,000 in premiums to pay for. So for each actual case of breast cancer found which costs $15K or $35K to fix, we’re paying $50,000 to find it [for which the insurance company collects between $75,000 and $100,000 to pay on our behalf], and we’re also spending between $1,000 and $10,000 [which costs between $1,500 and $20,000 for insurance to cover for us] to find out about the false positives.

Spending up to $120,000 on insurance premiums to provide up to $60,000 of medical care, to find one $15,000 or $35,000 case of breast cancer. Aren’t you glad I didn’t go with the greater figure of British screenings? We’d have been spending twice these amounts to find the same cost of illness.

Think it will be any better by having a “single-payer” system where the US government – like Britain – pays for all this out of taxes?

The government still has the same overhead that the insurance company ever did [and arguably more] – they have to hire people to process paperwork, investigate fraud and mere overcharges, process more paperwork, handle the irate phone calls from the people whose treatment was denied because it was deemed to be “medically unnecessary” [which, in the Medicaid system, is the excuse they use when they run out of money in the first place because “we’re rationing your healthcare” is considered rude], and process yet more paperwork.

They’re still going to collect $200 in taxes to pay for $100 in preventive diagnostics. Because that’s what Britain is doing ... and it’s why they’re going broke doing it. It’s what France is doing ... and why they started allowing people to opt out of mandatory state health care in favor of insurance which operates, in France, like insurance is supposed to and doesn’t cover routine care and preventives. It’s what Canada was doing ... stress on “was”, because they have undertaken steps to reduce the cost-ineffective aspects of health care of which breast cancer screening is just one example.

And finally, it’s what Greece continues to do, with Germany’s money, because they have none of their own anymore, because they spent it all giving away free education, free jobs [mostly working for the government], free healthcare, free vacations, and free pensions at the age of 50 ... when British women are just starting to get screened for breast cancer.

Yes, preventive screenings save lives. But it is not cost-effective. You spend $200 to get $100 of medical screening; you provide $50,000 of medical screening to find one patient who is cured for $15,000 or $35,000.

There’s 310,000,000 Americans – 165,000,000 American women ... 120,000,000 American women over the age of 40 when breast cancer screening begins in this country. This is 240,000 sets of the one-in-500 example of giving $100,000 to the insurance company to pay for $50,000 of doctoring to find one $15K or $35K illness and 10 cases of false positive that costs $20,000 for $10,000 of doctoring to figure out it’s a false alarm. Collectively we are giving insurance companies $24Billion to pay for $12Billion of medical service, which is finding between $3.6Billion and $8.4Billion of illness.

Do those numbers better indicate the seriousness? The difference between $12B and $24B is what we’re paying our personal assistants to pay our regular doctor bills, the ones that we’ll have to pay regardless. Why are we volunteering to pay double the true cost? Do we love insurance companies that much?

And this is just for one disease; how many diseases are there for which we are doing very similar things? How many “lifestyle choices”, Sandra Fluke?

How much do we spend each year immunizing against pertussis? What does pertussis cost to someone who contracts it? How many times does that occur ... even without immunization? A brief perusal of the numbers and doing the math shows another non-cost-effective insurance coverage – giving insurance companies a few million to pay for several hundred thousand dollars of serum and a two-cent syringe, to prevent each $10,000 case of coughing up a lung.

If you don’t want whooping cough – and who would – pay for your own damned immunization. Like mammograms, it’s smart to do, and it saves a life here and there. But it’s not smart to make everyone else pay for it for you.

Everyone paying means overpaying, and that means eventually running out of money. ...which, when governments do it, tends to lead to revolutions and/or invasions and/or riots and/or starvation, but, as Britain, France, Canada and Greece [et al] are finding out, it means the absolute loss of those things you thought you were so clever and so enlightened and so politically righteous to give yourselves.

You were none of those things. You were, instead, lazy, wasteful, greedy and ignorant.

Nota bene: The figures provided above are a combination of numbers from the British medical Journal The Lancet, from the American Cancer Society, CDC, and WHO, and are entirely consistent with the health care reality in the US, not to mention Britain, even if it is worst-casing the situation, rounding for ease of arithmetic [the average cost of a mammogram is, in fact, $102], and assuming that everyone gets routine mammograms; they don’t – not by a long-shot.